Nutrition and Feeding Care Plan
          The nutrition and feeding care plan defines all members of the care team, communication guidelines (how, when, and how often),
          and all information on a child’s diet and feeding needs for this child while in child care.
          Name of Child: _________________________________________________         Date: 
          Facility Name: _________________________________________________
          Team Member Names and Titles (parents of the child are to be included)
          Care Coordinator (responsible for developing and administering Nutrition and Feeding Care Plan):  
                                                i If training is necessary, then all team members will be trained.
          oIndividualized Family Service Plan (IFSP) attached         o Individualized Education Plan (IEP) attached
          Communication
          What is the team’s communication goal and how will it be achieved (notes, communication log, phone calls, meetings, etc.):
          How often will team communication occur:   o Daily    o Weekly    o Monthly    o Bi-monthly   o Other 
          Date and time specifics:      
          Specific Diet Information
          v  Medical documentation provided and attached:       o Yes       o No     oNot Needed
          Specific nutrition/feeding-related needs and any safety issues:  
          v  Foods to avoid (allergies and/or intolerances): 
          Planned strategies to support the child’s needs:        
          Plan for absences of personnel trained and responsible for nutrition/feeding-related procedure(s): 
          v  Food texture/consistency needs:      
          v  Special dietary needs:      
          v  Other:      
          Eating Equipment/Positioning
          v  Physical Therapist (PT) and/or Occupational Therapist (OT) consult provided        o Yes     oNo      oNot Needed
          Special equipment needed:      
          Specific body positioning for feeding (attach additional documentation as necessary):      
          Page 1 of 2                                                                         California Childcare Health Program   cchp.ucsf.edu    rev. 09/18
           Behavior Changes (be specific when listing changes in behavior that arise before, during, or after feeding/eating)
           Medical Information
           o Information Exchange Form completed by Health Care Provider is in child’s file onsite. 
           v  Medication to be administered as part of feeding routine:      o Yes    oNo
           o Medication Administration Form completed by health care provider and parents is in child’s file on-site (including type of 
               medication, who administers, when administered, potential side effects, etc.) 
           Tube Feeding Information
           Primary person responsible for daily feeding: 
           Additional person to support feeding:      
           oBreast Milk      oFormula (list brand information):
           Time(s) of day:      
           Volume (how much to feed): ____________________   Rate of flow: ____________________ Length of feeding: 
           Position of child:      
           oOral feeding and/or stimulation (attach detailed instructions as necessary):
           Special Training Needed by Staff
           Training monitored by: _________________________________________
           1) Type (be specific):
           Training done by: _____________________________________________                   Date of Training: 
           2) Type (be specific):
           Training done by: _____________________________________________                   Date of Training: 
           Additional Information (include any unusual episodes that might arise while in care and how the situation should be handled)
           Emergency Procedures
           oSpecial emergency and/or medical procedure required (additional documentation attached)
           Emergency instructions: 
           Emergency contact: _______________________________________________  Telephone: 
           Follow-up: Updates/Revisions
           This Nutrition and Feeding Care Plan is to be updated/revised whenever child’s health status changes or at least every ___ months as
           a result of the collective input from team members.
           Due date for revision and team meeting: ______________
           Page 2 of 2                                                                          California Childcare Health Program   cchp.ucsf.edu   rev. 09/18